Surviving Spouse or Partner Pension application information (Issued under sections 27, 67 and 213 of the Veterans Support Act 2014)

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Surviving Spouse or Partner Pension application information (Issued under sections 27, 67 and 213 of the Veterans Support Act 2014)"

Transcription

1 Surviving Spouse or Partner Pension application information (Issued under sections 27, 67 and 213 of the Veterans Support Act 2014) Please read before you complete this form Eligibility (sections 66-67, Veterans Support Act 2014) This application form is for a surviving spouse or partner of a deceased veteran. The Surviving Spouse or Partner Pension provides financial support to the spouse or partner of deceased veterans either affected by significant service-related impairment during their lives or whose death was due to qualifying service. It is not income or asset tested in New Zealand. To apply, you must fully complete this application form and provide any supporting information or evidence required by Veterans Affairs (VA). If your application is incomplete it will be returned to you unprocessed. Further information can be found in the Surviving Spouse or Partner Pension factsheet on our website. You may be eligible for a Surviving Spouse or Partner Pension if the following criteria is met: the veteran s death was service-related; OR at the time of the veteran s death, the veteran was receiving a permanent War Disablement Pension of 70% or more, or a permanent Disablement Pension of 52% or more in relation to whole-person impairment; OR VA considers that had the veteran not died, the veteran would have been eligible to receive a pension to the extent of impairment specified above. The above does not apply if, immediately before the veteran s death: the veteran and the claimant were living apart or were not maintaining a relationship in the nature of marriage; and the claimant was not contributing to the veteran s day-to-day welfare, unless these circumstances occurred principally because of health, imprisonment, or employment obligations of the veteran or the claimant. Refer to the list of qualifying service deployments and dates on our website. When does a pension cease? (sections 68-70, Veterans Support Act 2014) Process for deciding claims (sections 11-21, Veterans Support Act 2014) Offences (section 270, Veterans Support Act 2014) Assistance A surviving spouse or partner is no longer entitled to the Surviving Spouse or Partner Pension if they enter into a new relationship (marriage, civil union or de facto). They can however elect to receive a payment equivalent to two years worth of the Surviving Spouse or Partner Pension, either periodically or as a lump sum. A surviving spouse or partner can have their entitlement to a Surviving Spouse or Partner Pension reinstated if their new relationship comes to an end within 5 years after the start of the relationship. A surviving spouse or partner s entitlement to the Surviving Spouse or Partner Pension ceases 28 days after their death. VA will make a decision on your claim within 30 working days of receipt of the application. However, the 30 working days does not include any period while VA is waiting for further information that it requires to determine whether to accept the claim. If the application is accepted the pension will be paid from the day after the veteran s death if the application is received by VA within 6 months of the veteran s death; or the day on which the application was received by VA, if received more than 6 months after the veteran s death. It is an offence to make a false statement or provide misleading information and anyone who does so commits an offence against this section and is liable on conviction to a term of imprisonment not exceeding 3 months or a fine not exceeding $5,000. If you have any questions or require assistance completing this form, you can contact us using the details shown below or a person from an ex-service organisation: Freephone / VETERANS (or if calling from overseas) You can or visit our website: VA05-26 April 2016 Information Sheet 1/2

2 Surviving Spouse or Partner Pension application information (Issued under sections 27, 67 and 213 of the Veterans Support Act 2014) Completing your application This application form must be completed and signed by the claimant or: any person requested by the claimant to complete the form (the claimant must complete the Signature & Acknowledgement); or the holder of a Power of Attorney or other recognised authority (refer to page 8). Step 1: Complete pages 1-4*; read the Privacy Statement on page 7; and complete the Signature & Acknowledgement on page 8. If a question is not applicable, please write N/A. If there is insufficient space to answer a question, please include additional sheet/s of paper to complete your answer, including the question or page number it relates to. *Please note: Page 3 (Late Veteran s Employment and Service History) does not need to be completed if the late veteran was in receipt of a War Disablement Pension or Disablement Pension. Step 2: If required, arrange completion of pages 5-6* (Late Veteran s Medical Certificate) by the late veteran s Medical Practitioner. Any costs associated with the gathering of information or completion of the Medical Certificate will need to be met by the claimant. *Please note: Pages 5-6 (Late Veteran s Medical Certificate) do not need to be completed if: the primary cause of death was an accepted disability; or VA has already determined the veteran s death was service-related, or that the qualifying criteria for a Surviving Spouse or Partner Pension has already been met. If the late veteran was in receipt of a permanent War Disablement Pension of 70% or more, or a permanent Disablement Pension of 52% in relation to whole-person impairment, for accepted disabilities that were not the cause of death, then pages 5-6 only need to be completed if there is additional medical information that relates the death to service. Step 3: Complete the Checklist and Receipt on page 9, then send your fully completed application and all supporting documentation to VA at the address shown. Documents required with this application The following documents must be submitted with your application: Certified copies of two forms of identification (one from List A and one from List B): List A: Full Birth Certificate (showing your parent s names), Current Passport. and List B: Current Drivers Licence, Firearms Licence, SuperGold Card, Community Services Card. NB. We require a certified copy of both sides of the licence/card. An original or certified copy of your bank statement showing the account number and name OR a pre printed deposit slip stamped by your bank. A certified copy of the late veteran s death certificate (if not already provided). A certified copy of your marriage or civil union certificate. If you were in a de facto relationship you will need to provide a statutory declaration regarding the duration and nature of your relationship and supporting documentation, such as home ownership documents, joint bank account statements, joint utilities etc that show you were financially interdependent. A certified copy is an original document that has been photocopied and certified as a true copy by one of the following: Work and Income; Justice of the Peace; Solicitor; Police Officer; Registered Medical Professional; Court Registrar; or other people authorised to take statutory declarations. VA05-26 April 2016 Information Sheet 2/2

3 Claimant s Personal Details 1 Work and Income / Client Number (if known) Surviving Spouse or Partner Pension application form 2 Title (tick) 3 Surname Mr Mrs Miss Ms Dr Other 4 Given Name/s 5 Other Known Names List other names that you use now or in the past including maiden name/s 6 Date of Birth / / 7 Residential Address Country (if not New Zealand) Post Code 8 Postal Address (if different from residential address) Country (if not New Zealand) Post Code 9 Other Contact Details Home Phone Mobile Number Work Phone Fax Number Address 10 Next of kin details Please provide contact details of a next of kin not living at your address Name Address Contact Details Relationship to claimant VA05-26 April 2016 Surviving Spouse or Partner Pension application form 1/9

4 11 Dependant Children Children who are living with you as family members whom you financially support, including: your natural children; stepchildren; children at boarding school; adopted children; and grandchildren. Do you have any dependant children? No Yes If yes, please list details below Name Date of Birth Relationship to late veteran Name Date of Birth Relationship to late veteran 12 Bank Details This will be the account your Surviving Spouse or Partner Pension will be paid into if granted Name of bank Branch Account Name Write your bank account number below and attach an original or certified copy of your bank statement showing the account number and name OR a pre printed deposit slip stamped by your bank Bank Branch Account number Late Veteran s Personal Details 13 Work and Income / Client Number (if known) 14 Title Mr Mrs Miss Ms Dr Other 15 Surname 16 Given Name/s Date of Birth Date of Death / / / / 19 Residential Address (at time of death) Country (if not New Zealand) Post Code 20 War Disablement Pension / Disablement Pension Did the late veteran receive a War Disablement Pension or Disablement Pension? No If No, go to page 3 Yes If yes, go to page 4 VA05-26 April 2016 Surviving Spouse or Partner Pension application form 2/9

5 Late Veteran s Employment and Service History Complete page 3 if the late veteran was NOT in receipt of a War Disablement Pension or a Disablement Pension 21 Details of Employment Please provide details of the veteran s employment before and after service in the NZ Defence Force (NZDF) Commenced Ended Employer Nature of Work Month Year Month Year 22 Qualifying Service Refer to the list of qualifying service deployments and dates on our website Please state the veteran s qualifying service deployment/s below: 23 Details of Service Please provide details of the veteran s service in NZDF and forces of other countries (if known) Service Number Trade/Corps/Branch Nature of duties (and country served for) Enlistment & Discharge dates (if known) / / to / / 24 Operational Deployments Did the veteran serve overseas? No Yes If yes, please list details below (if known) Commenced Ended Operational Deployment Role Month Year Month Year 25 Prisoner of War Was the veteran a Prisoner of War? No Yes If yes, please state where the veteran was captured and imprisoned, and dates if known VA05-26 April 2016 Surviving Spouse or Partner Pension application form 3/9

6 Your Relationship Details 26 Your relationship status at time of veteran s death Married Civil Union De facto Separated Divorced Single 27 Living arrangements Were you living with the veteran at the time of the veteran s death? If no, please give the reasons why and the date you stopped living together: No Yes 28 Relationships Since the veteran s death, have you entered into a new relationship? If yes, please complete the questions below: No Yes Details of your current or most recent relationship Married Civil Union De facto Date relationship commenced Spouse or partner s surname Spouse or partner s first names Date relationship ended (if applicable) Details of your second most recent relationship Married Civil Union De facto Date relationship commenced Spouse or partner s surname Spouse or partner s first names Date relationship ended If you have had more than two marriages, civil unions or de facto relationships since the veteran s death please continue on a separate piece of paper and attach VA05-26 April 2016 Surviving Spouse or Partner Pension application form 4/9

7 Late Veteran s Medical Certificate - to be completed by a Medical Practitioner Refer to page 2 of the Information Sheet to check if the Medical Certificate requires completion 29 Veteran s Name 30 Veterans NHI Number 31 Enrolment History Was the veteran enrolled with your practice? No Yes If yes, how long had they been enrolled with you? Years Months If no, provide the name and contact details of their usual medical practitioner (if known) Name of Practitioner Practice Name 32 Details of the conditions the veteran had prior to his/her death Medical diagnosis Date first diagnosed How long did you treat this condition for? Was this condition current at the time of the veteran s death? Yes No What would you assess the level of disablement/severity to have been? Did the veteran have a specialist assessment of this condition? Yes No If yes please attach a copy of the report, or provide contact details of specialist Medical diagnosis Date first diagnosed How long did you treat this condition for? Was this condition current at the time of the veteran s death? Yes No What would you assess the level of disablement/severity to have been? Did the veteran have a specialist assessment of this condition? Yes No If yes please attach a copy of the report, or provide contact details of specialist Medical diagnosis Date first diagnosed How long did you treat this condition for? Was this condition current at the time of the veteran s death? Yes No What would you assess the level of disablement/severity to have been? Did the veteran have a specialist assessment of this condition? Yes No If yes please attach a copy of the report, or provide contact details of specialist VA05-26 April 2016 Surviving Spouse or Partner Pension application form 5/9

8 Late Veteran s Medical Certificate - to be completed by a Medical Practitioner 33 General comments on the late veteran s overall health 34 Medical Practitioner Identity HPI No. Medical Council Registration No. Name Practice Stamp (or address and telephone) Medical Practitioner Signature / / Please attach supporting documentation such as copies of medical reports, blood test results etc. VA05-26 April 2016 Surviving Spouse or Partner Pension application form 6/9

9 Privacy Statement The Veterans Support Act 2014 (the Act) which is administered by the New Zealand Defence Force allows us to obtain further information about you to help us assess your application. This may happen when you apply for or are receiving an entitlement. The Privacy Act 1993 requires us to tell you why we collect the information and what we will do with it. You are not required to give Veterans Affairs any information, but if you do not provide all the information we ask for, your application for an entitlement and/or assistance may not be able to be processed and may be returned to you. Why we collect information The information we collect about you will be held by Veterans' Affairs New Zealand (Veterans Affairs), which is a unit of the New Zealand Defence Force. We use this information for the purpose of: Administering claims and entitlements under the Veterans Support Act 2014 Enabling a comprehensive claims database to be maintained To monitor and evaluate the nature, incidence, severity and consequences of service-related illness and injuries The provision of appropriate treatment, rehabilitation and compensation Facilitating the monitoring of the operation of the Act and policy development The information you give us may be shared with other government agencies for several purposes, such as the Ministry of Social Development consistency with other benefits, Accident Compensation Commission consistency with other claims, Maritime New Zealand for merchant navy records, Inland Revenue for payment of tax on taxable entitlements, Archives New Zealand for service records and the Department of Internal Affairs to verify your date of birth. We only collect information needed to manage the entitlements we administer. Using and sharing personal and health-related information Veterans Affairs may exchange information about you with your health practitioner(s) in order to provide you with the correct entitlements and assistance, to clarify any health-related information you give us and for the purposes of putting in place treatment and rehabilitation if required. Veterans Affairs will also collect personal and health information from a variety of sources including information provided when making an application to Veterans Affairs, information supplied by others including treatment providers, and other government agencies. The information we collect about you can be via various channels, such as , telephone, face to face and in various formats, such as letters, forms and electronic file notes. Veterans Affairs uses personal information provided only for the purposes consistent with the reason it was obtained and will not share it with other parties unless there is a legal authority to do so. You have the right to access and correct your personal information You may access personal information that we hold about you. You can ask us to correct errors contained in the information we have about you. You can contact us at anytime if you have concerns on what information about you we are collecting and how it is or may be used. Please complete the Signature & Acknowledgement on page 8 VA05-26 April 2016 Surviving Spouse or Partner Pension application form 7/9

10 Signature & Acknowledgement By signing this application form I acknowledge and understand that: The information provided in this application form is, to the best of my knowledge, true and complete. As part of processing this application, Veterans Affairs may obtain further information in addition to what I have provided. I am consenting to the release and collection of health, clinical or other information to Veterans Affairs held by any health practitioner, hospital, clinic, insurance company, Accident Compensation Commission, Ministry of Social Development, Department of Internal Affairs or other persons or agencies for the purposes of assessing and processing this application and administering any resulting entitlement or assistance. I am aware there are penalties for providing false information as set out in the information sheet at the front of this application. I have read and understand the Privacy Statement contained in this form. The Power of Attorney or Enduring Power of Attorney document attached to this application is current (where the application is being signed by a person holding this document). Claimant or Power of Attorney s name (print) Signature Date / / If you had assistance completing this form, print the persons name (and organisation they represent if applicable) below: If the claimant is unable to sign due to physical or mental incapacity, the application must be signed by a person with authority to act on behalf of the claimant. If this situation applies you must also attach a certified copy of at least one of the following documents: Power of Attorney or Enduring Power of Attorney (in relation to Property) Court Order Certificate of Administration (from the Public Trustee) VA05-26 April 2016 Surviving Spouse or Partner Pension application form 8/9

11 Checklist Please complete the checklist below to ensure your application is complete: I have fully completed my application form. I have provided certified copies of two forms of identification. I have attached an original or certified copy of my bank statement OR a pre printed deposit slip stamped by my bank. I have provided a certified copy of the late veteran s death certificate (if not already provided). I have provided a certified copy of my marriage or civil union certificate; or if in a de facto relationship a statutory declaration and supporting documentation. If applicable, the late veteran s Medical Practitioner has completed the Medical Certificate on pages 5-6 and attached medical records to support the application. I have read the Privacy Statement on page 7 and completed the Signature & Acknowledgement on page 8. I have written my name and address in the application receipt below (we will return this to you when we receive your application for your records). Send your completed application to: Veterans Affairs PO Box 5146 Lambton Quay WELLINGTON 6140 Surviving Spouse or Partner Pension Application Receipt This is to acknowledge Veterans Affairs has received your application. required you will be advised of a decision within 30 working days. Provided no further information is Please write your name and address details below: Office Date Stamp VA05-26 April 2016 Surviving Spouse or Partner Pension application form 9/9

Retirement Lump Sum application information (Issued under sections 27, 149, 150, 151 and 213 of the Veterans Support Act 2014)

Retirement Lump Sum application information (Issued under sections 27, 149, 150, 151 and 213 of the Veterans Support Act 2014) Retirement Lump Sum application information (Issued under sections 27, 149, 150, 151 and 213 of the Act 2014) Please read before you complete this form This application form is for veterans reaching the

More information

Weekly Compensation Scheme Two

Weekly Compensation Scheme Two Weekly Compensation Scheme Two Veteran s Personal Details 1 Veterans Affairs number (if known) 2 Title Rank Mr Mrs Ms Other 3 Last name 4 First name/s 5 Other name/s known as 6 Date of birth / / 7 Residential

More information

This application will be processed under the terms of the Agreement between the New Zealand Government and the Government of Malta.

This application will be processed under the terms of the Agreement between the New Zealand Government and the Government of Malta. Application for New Zealand Superannuation under a Social Security Agreement Malta This application will be processed under the terms of the Agreement between the New Zealand Government and the Government

More information

Application for New Zealand Payment Overseas

Application for New Zealand Payment Overseas Application for New Zealand Payment Overseas CLIENT NUMBER Please read this before you start What to bring 3 Please complete this application if you intend to: live in an overseas country for more than

More information

Claim for Compensation for a Work-related death

Claim for Compensation for a Work-related death SRC 184 (March 2014) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act)

More information

CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH

CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH CLAIM FOR COMPENSATION FOR A WORK-RELATED DEATH Seafarers Rehabilitation and Compensation Act 1992 Information about claiming compensation In this document, all references to the employer mean the employer

More information

New Zealand Superannuation Application Spouse/Partner

New Zealand Superannuation Application Spouse/Partner New Zealand Superannuation Application Spouse/Partner If you need help with this form call us on % 0800 552 002. Please read this before you start Being included in your spouse/ partner s New Zealand Superannuation

More information

Deferred Loan Application

Deferred Loan Application Deferred Loan Application MINISTRY OF HEALTH MANATU HAUO RA Deferred Loans When a residential care loan becomes repayable, a deferred loan can be offered to people in certain circumstances. Residential

More information

Special Needs Grant International Custody Dispute Payment

Special Needs Grant International Custody Dispute Payment Special Needs Grant International Custody Dispute Payment CLIENT NUMBER If you need help with this form call us on % 0800 559 009. Who can get this payment If you need help filling in this form, please

More information

Community Services Card Application

Community Services Card Application Community Services Card Application Who can get a Community Services Card? Mehemea he patai ou waea mai ki. Me e uianga taau e ringi mai ia matou, numero. Mo so o sau fesili, telefoni mai. If you have

More information

Community Services Card Application

Community Services Card Application Community Services Card Application Who can get a Community Services Card? Mehemea he patai ou waea mai ki. Me e uianga taau e ringi mai ia matou, numero. Mo so o sau fesili, telefoni mai. If you have

More information

Funeral Grant application

Funeral Grant application Funeral Grant application A Funeral Grant may help with some of the funeral costs for a person who has died. Funeral Grants are asset and income tested. Other conditions also apply. For more information:

More information

Claim for Compensation for a Work-related death

Claim for Compensation for a Work-related death SRC184(Feb2008) Claim for Compensation for a Work-related death This form is to be completed if you wish to claim compensation under the Safety, Rehabilitation and Compensation Act 1988 (SRC Act) for the

More information

New Zealand Superannuation application

New Zealand Superannuation application New Zealand Superannuation application Why not fill in your application online? Our interactive form will guide you through only the questions you need to answer. When you have finished, you will need

More information

CLAIM FOR WORKERS COMPENSATION

CLAIM FOR WORKERS COMPENSATION CLAIM FOR WORKERS COMPENSATION Seafarers Rehabilitation and Compensation Act 1992 Information about claiming workers compensation In this document, all references to the employer mean the employer against

More information

Asbestos-Related Diseases - Claim for Compensation

Asbestos-Related Diseases - Claim for Compensation Asbestos-Related Diseases - Claim for Compensation (Member of the family) Asbestos-Related Diseases (Occupational Exposure) Compensation Act 2011 2 WHO CAN MAKE A CLAIM Certain family members of a person

More information

Appointment of an agent form

Appointment of an agent form Appointment of an agent form An agent is someone who can act for you when dealing with the Ministry of Social Development (Work and Income, Senior Services and Housing Assessment). Choosing an agent You

More information

Partnership Support Form for Residence

Partnership Support Form for Residence OFFICE USE ONLY Client no.: Date received: Application no.: March 2015 INZ 1178 Partnership Support Form for Residence For applications under the Partnership Category of Residence Instructions tes for

More information

Payment of unclaimed superannuation money

Payment of unclaimed superannuation money Instructions and form for super fund members Payment of unclaimed superannuation money How to complete your Application for payment of unclaimed superannuation money individual. For information about unclaimed

More information

Addition Of A Power Of Attorney / Receiver / Deputy Application Form

Addition Of A Power Of Attorney / Receiver / Deputy Application Form OFFICE USE ONLY Customer Number for the Original Customer: Branch Code: Please complete this form in BLACK INK and using BLOCK CAPITALS. For further details on how to register an Attorney / Receiver /

More information

Form 275 Notice of claim for damages

Form 275 Notice of claim for damages Department of Justice and Attorney-General Workers Compensation Regulator Form 275 Notice of claim for damages Version 3 Workers Compensation and Rehabilitation Act 2003 Section 275 This is an approved

More information

Fit and proper person form

Fit and proper person form Fit and proper person form Last updated: 9 March 2015 About this form To hold any maritime document(s), you are required to be a fit and proper person. This applies at all times while the documents are

More information

Childcare and OSCAR Subsidy Application

Childcare and OSCAR Subsidy Application Childcare and OSCAR Subsidy Application If you need help with this form call us on % 0800 559 009. Who can get this subsidy If you need help filling in this form, please ask at your nearest Work and Income

More information

Life Events/Salary Increase cover

Life Events/Salary Increase cover Fact sheet and form Life Events/Salary Increase cover What this fact sheet covers This fact sheet provides information about Life Events insurance cover and Salary Increase cover available through our

More information

Application for adoption information: Relative or guardian of adopted person who is deceased or does not have capacity

Application for adoption information: Relative or guardian of adopted person who is deceased or does not have capacity The purpose of the application for adoption information: is deceased or does not have capacity form This form is for use by a relative or guardian of an adult adopted person to apply for adoption information

More information

Application Form and Lodgement Guide

Application Form and Lodgement Guide First Home Owner Grant Application Form and Lodgement Guide Please read the Terms used for explanations in completing the application 4 easy steps to claim your grant 01 02 03 04 Read lodgement guide Important

More information

APPLICATION FOR NEW CERTIFICATE OF COMPETENCE

APPLICATION FOR NEW CERTIFICATE OF COMPETENCE APPLICATION FOR NEW CERTIFICATE OF COMPETENCE This is an application form for a certificate of competence under the Health and Safety in Employment (Mining Operations and Quarrying Operations) Regulations

More information

Disability Allowance Application

Disability Allowance Application Disability Allowance Application CLIENT NUMBER If you need help with this form call us on % 0800 559 009. Who can get Disability Allowance? Please read this before you start Name If you, or a family member,

More information

Authorised Signatory Form

Authorised Signatory Form Form Complete this form: to give a person other than your adviser the authority to act on your existing margin lending facility in all matters as if they were you (including but not limited to increasing

More information

Complete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying super fund.

Complete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying super fund. Benefit access Gesb Super and West State Super SUP E R ANNUATION Complete this form to withdraw part or all of your benefit as a lump sum, roll over to another GESB account and/or to another complying

More information

Form US-Individual 2002

Form US-Individual 2002 Form US-Individual 2002 United Kingdom/United States of America Double Taxation Convention (SI 2002 Number 2848) Application for relief at source from United Kingdom income tax Claim to repayment of United

More information

Funeral Grant Application

Funeral Grant Application Funeral Grant Application CLIENT NUMBER (of person applying) Please read this before you start A funeral grant may help with some of the funeral costs of someone who has died. You may get a Funeral Grant

More information

Change My Insurance Details Form

Change My Insurance Details Form Change My Insurance Details Form Please complete and return this form to: NESS Super, Locked Bag 20, Parramatta NSW 2124 Complete in pen using CAPITAL letters or type directly into this form and print

More information

KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL /APPROVAL APPLICATION FORM

KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL /APPROVAL APPLICATION FORM KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL /APPROVAL APPLICATION FORM and KiwiSaver First-Home Withdrawal DETERMINATION FOR PREVIOUS HOME OWNER FORM KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL/APPROVAL

More information

IR 200 January 2008. Working for Families Tax Credits registration pack

IR 200 January 2008. Working for Families Tax Credits registration pack IR 200 January 2008 Working for Families Tax Credits registration pack WORKING FOR FAMILIES TAX CREDITS REGISTRATION 3 Thank you for asking about Working for Families Tax Credits*. In this pack you ll

More information

Lump sum benefit payment request for your superannuation or account based pension

Lump sum benefit payment request for your superannuation or account based pension Lump sum benefit payment request for your superannuation or account based pension How to claim a benefit To claim a benefit you will need to complete the attached Benefit Payment Request and send it direct

More information

LAST NAME GIVEN NAME(S) DATE CEASED / / LAST NAME GIVEN NAME(S) DATE CEASED / /

LAST NAME GIVEN NAME(S) DATE CEASED / / LAST NAME GIVEN NAME(S) DATE CEASED / / Application by an INDIVIDUAL FOR A NSW SECURITY LICENCE under the Mutual Recognition Act 1992 and/or Trans-Tasman Mutual Recognition Act 1997 OFFICE USE ONLY Application No: - Receipt No: - Trim No: To

More information

Portability and rollover

Portability and rollover Fact sheet and form Portability and rollover What this fact sheet covers This fact sheet explains how to make a rollover of all or part of your UniSuper account to another complying super fund. Who is

More information

Fact Sheet > Super SA > Triple S > Your Questions Answered MAKING AN INCOME PROTECTION CLAIM

Fact Sheet > Super SA > Triple S > Your Questions Answered MAKING AN INCOME PROTECTION CLAIM Fact Sheet > Super SA > Triple S > Your Questions Answered MAKING AN INCOME PROTECTION CLAIM > 1 IN THIS FACT SHEET > What is Income Protection (IP)? > Circumstances under which IP will not be paid > Step

More information

Blue Care Income Protection Claim Form

Blue Care Income Protection Claim Form Blue Care Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all fields

More information

APPLICATION FORM - PERSONAL INJURY (Do not use for fatal injuries)

APPLICATION FORM - PERSONAL INJURY (Do not use for fatal injuries) The Compensation Agency Royston House 34 Upper Queen Street Belfast BT1 6FD www.compensationni.gov.uk THE COMPENSATION Agency Reference number For official use only T1 Criminal Injuries Compensation Scheme

More information

Asbestos-Related Diseases - Claim for Compensation

Asbestos-Related Diseases - Claim for Compensation Asbestos-Related Diseases - Claim for Compensation (Worker) Asbestos-Related Diseases (Occupational Exposure) Compensation Act 2011 1 WHO CAN MAKE A CLAIM 1. Person with an asbestos-related disease You

More information

Pension Application Form

Pension Application Form PITCHER RETIREMENT PRP PLAN Pension Application Form Member Details Mr Mrs Miss Ms Other First given name Middle names Family name Date of Birth / / Residential address Suburb/town State Postcode Daytime

More information

Sponsorship Form for Temporary Entry

Sponsorship Form for Temporary Entry OFFICE USE ONLY Client no.: Date received: Application no.: May 2016 INZ 1025 Sponsorship Form for Temporary Entry Supporting information for a visitor visa, work visa or student visa application Who can

More information

Student Allowance/Student Loan/Scholarship Overseas study application form

Student Allowance/Student Loan/Scholarship Overseas study application form Student Allowance/Student Loan/Scholarship Overseas study application form Complete this form if you want to apply for a Student Allowance/Student Loan/Scholarship for overseas study. You can also apply

More information

Notice of Accident Claim Form

Notice of Accident Claim Form Insurer s Claim Reference Number Queensland Compulsory Third Party Insurance (CTP) Notice of Accident Claim Form (Fatal Injury) for accidents occurring on and after 1st October 2000 Motor Accident Insurance

More information

FIRST HOME OWNER RATE OF DUTY INDIAN OCEAN TERRITORIES

FIRST HOME OWNER RATE OF DUTY INDIAN OCEAN TERRITORIES FIRST HOME OWNER RATE OF DUTY INDIAN OCEAN TERRITORIES SECTIONS 141 146 OF THE DUTIES ACT 2008 (WA)(CI) & (CKI) APPLICATION FORM AND LODGMENT GUIDE A first home owner who is not eligible for the First

More information

NHS Injury Benefits - Application for Permanent Injury Benefit.

NHS Injury Benefits - Application for Permanent Injury Benefit. NHS Injury Benefits - Application for Permanent Injury Benefit. Important: Please complete this form in CAPITAL LETTERS and in BLACK INK TIA ref: IB Section A Section B To be completed by the Employing

More information

Advance Retirement Suite Super Early Release Financial Hardship Application

Advance Retirement Suite Super Early Release Financial Hardship Application Advance Retirement Suite Super Early Release Financial Hardship Application Trustee: BT Funds Management Ltd (BTFM) ABN 63 002 916 458 AFSL 233724 GUIDE TO COMPLETING THIS FORM > > Use this form if you

More information

Entrepreneur Residence Guide

Entrepreneur Residence Guide December 2015 INZ 1057 Entrepreneur Residence Guide Entrepreneur Residence Category Information about this guide The purpose of this guide is to help you complete the Entrepreneur Residence Application

More information

Application for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application

Application for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application Application for Benefits under the Motor Accidents (Compensation) Act Fatal Accident Application Losing a family member in a motor vehicle accident is a traumatic and difficult experience. The Motor Accidents

More information

A helpful guide for first home buyers. Westpac KiwiSaver Scheme First Home Purchase Withdrawal

A helpful guide for first home buyers. Westpac KiwiSaver Scheme First Home Purchase Withdrawal A helpful guide for first home buyers. Westpac KiwiSaver Scheme First Home Purchase Withdrawal BT Funds Management (NZ) Limited is the scheme provider and Westpac New Zealand Limited is the distributor

More information

Wesley Mission Income Protection Claim Form

Wesley Mission Income Protection Claim Form Wesley Mission Income Protection Claim Form INCOME PROTECTION CLAIMS In order to alleviate any delay in the processing time of your claim, please ensure the following: The claim form is returned with all

More information

DETERMINATION FOR PREVIOUS HOME OWNER FORM

DETERMINATION FOR PREVIOUS HOME OWNER FORM KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL/ APPLICATION FORM and KiwiSaver First-Home Withdrawal DETERMINATION FOR PREVIOUS HOME OWNER FORM KiwiSaver First-Home Deposit Subsidy PRE-APPROVAL/APPLICATION

More information

Medical Card and GP Visit Card Application Form - People Aged 70 Years or Older MC1(a)

Medical Card and GP Visit Card Application Form - People Aged 70 Years or Older MC1(a) Medical Card and GP Visit Card Application Form - People Aged 70 Years or Older MC1(a) Who should use this form? People 70 years of age or older and their spouse or partner should use this form when applying

More information

by or on behalf of a stateless person born before 1 January 1983

by or on behalf of a stateless person born before 1 January 1983 Form S1 Application for registration as - a British citizen, a British Overseas Territories citizen, or a British Overseas citizen by or on behalf of a stateless person born before 1 January 1983 IMPORTANT:

More information

Application for registration in New Zealand Part B: This form is to be accompanied by Part A [checklist] and all documents required on checklist

Application for registration in New Zealand Part B: This form is to be accompanied by Part A [checklist] and all documents required on checklist Application for registration in New Zealand Part B: This form is to be accompanied by Part A [checklist] and all documents required on checklist REG1 October 2015 For office use only Registration no: PO

More information

Change of Circumstances application form

Change of Circumstances application form Change of Circumstances application form Complete this form if your circumstances have changed in any way. The fastest and easiest way to tell us about changes is using MyStudyLink. Using a MyStudyLink

More information

Cessation of employment

Cessation of employment SR1 04/12 Cessation of employment Benefit application form Before you start Before you complete this benefit application form, please read the CSS Product Disclosure Statement. This form and the Explanatory

More information

Student Allowance Partner s application form

Student Allowance Partner s application form Student Allowance Partner s application form This form is to be completed by the partner 1 of the person applying for the Student Allowance. The student will also need to complete a Student Allowance application.

More information

FORM EU2. Application for a Permanent Residence Certificate For European Union Citizen

FORM EU2. Application for a Permanent Residence Certificate For European Union Citizen DATE STAMP epartment of Justice, Equality and Law Ref DEPARTMENT OF JUSTICE AND EQUALITY IRISH NATURALISATION & IMMIGRATION SERVICE FORM EU2 (FOR OFFICE USE ONLY) Application for a Permanent Residence

More information

APPLICATION FOR RETIREMENT (OLD AGE) AND INVALIDITY BENEFITS UNDER THE NATIONAL INSURANCE ACT OF 1965 JAMAICA

APPLICATION FOR RETIREMENT (OLD AGE) AND INVALIDITY BENEFITS UNDER THE NATIONAL INSURANCE ACT OF 1965 JAMAICA APPLICATION FOR RETIREMENT (OLD AGE) AND INVALIDITY BENEFITS UNDER THE NATIONAL INSURANCE ACT OF 1965 JAMAICA INSTRUCTIONS: I. This form is to be completed in BLOCK CAPITALS using black or blue ink pen;

More information

CLAIMING A BENEFIT FACT SHEET

CLAIMING A BENEFIT FACT SHEET Leaving your employer If you cease employment with your current employer, you can remain a member of Club Super. Your account will continue to receive investment earnings, and you will regularly receive

More information

Important information about transferring super to a New Zealand KiwiSaver scheme

Important information about transferring super to a New Zealand KiwiSaver scheme Important information about transferring super to a ew Zealand KiwiSaver scheme If you are moving permanently to ew Zealand, you can transfer your Accumulate Plus account balance to a ew Zealand KiwiSaver

More information

Application to register a change of name (adult 18+ years)

Application to register a change of name (adult 18+ years) Application to register a change of name (adult 18+ years) July 2014 Recognising the significance of life events Important information about your change of name application If you require access to a translation

More information

Disability/Sickness Claim

Disability/Sickness Claim Genworth Financial Step 1: Check Your Policy Documents 1 Disability/Sickness Claim Building 6 Chiswick Park 566 Chiswick High Road London W4 5HR 0870 900 0161 www.genworth.co.uk Important Notes You must

More information

Application for Approval to Provide Legal Aid Services_VERSION 2 Page 1 / 11

Application for Approval to Provide Legal Aid Services_VERSION 2 Page 1 / 11 Application for Approval to Provide Legal Aid Services Part 1 Please use this form if you are seeking approval as a provider of legal aid services, (lead provider, supervised provider or an employment

More information

Death Benefits under the Occupational Injuries Scheme

Death Benefits under the Occupational Injuries Scheme Claim form for Death Benefits under the Occupational Injuries Scheme SOCIAL WELFARE SERVICES OFFICE OB 61 Please place a tick ( ) at type of assistance you are applying for: Widow s/widower s Pension under

More information

Income Protection Initial Claim Form

Income Protection Initial Claim Form MLC Insurance Income Protection Initial Claim Form MLC Nominees Pty Limited ABN 93 002 814 959 AFSL 230702 RSE L0002998 The Universal Super Scheme ABN 44 928 361 101 R1056778 Superannuation Fund Number

More information

Fixed insurance cover

Fixed insurance cover Fact sheet and form Fixed insurance cover When it comes to insurance cover, one size doesn t necessarily fit all. That s why you have the ability to convert your Death and Total & Permanent Disablement

More information

Can the TAC help you?

Can the TAC help you? Can the TAC help you? The Transport Accident Commission (TAC) pays for the reasonable cost of treatment and support services for people injured in transport accidents. You may be eligible to have medical

More information

Claim form for Injury Benefit

Claim form for Injury Benefit Claim No. Stamp and date of receipt Claim form for Injury Benefit 1. A claim for Injury Benefit must be submitted not later than seven days from the commencement of incapacity. 2. When claiming in respect

More information

Withdrawal Form 1 July 2015

Withdrawal Form 1 July 2015 Withdrawal Form 1 July 2015 OnePath Life Limited ABN 33 009 657 176 AFSL 238 341 242 Pitt Street, Sydney NSW 2000 Customer Services Phone 133 665 Email customer@onepath.com.au Website onepath.com.au Instructions

More information

Public Sector Injury Benefit Scheme 2015

Public Sector Injury Benefit Scheme 2015 Public Sector Injury Benefit Scheme 2015 PSPA Ref: Application for Injury Benefit Important: Please complete this form in CAPITAL LETTERS and in BLACK INK Section A To be completed by the Employing Authority

More information

Claim for Approved Child Care payments

Claim for Approved Child Care payments Claim for Approved Child Care payments an annual lump sum payment for the 2014 2015 financial year Online Services When to use this form When to Claim Filling in this form Use our online services You do

More information

Employer Insurance Application

Employer Insurance Application for Property Focused Employer Sponsored Super Before you sign this application form, the Trustee or your financial adviser is obliged to give you the Property Focused Super Product Disclosure Statement

More information

Accessing your super early

Accessing your super early Accessing your super early If you have a terminal medical condition If you re suffering from a terminal medical condition you may be able to access your super before you reach your preservation age. Who

More information

Application for direct payment of government super contributions

Application for direct payment of government super contributions Instructions and form for retirees and estate trustees Application for direct payment of government super contributions WHO COMPLETES THIS APPLICATION You should complete this application if you want to

More information

Joint Account Application Form

Joint Account Application Form Joint Account Application Form You ll need to have a bank account with ANZ Bank New Zealand Limited (ANZ) to have access to this service. If you aren t already an ANZ bank account holder, simply visit

More information

Bring your Australian super home. ANZ KiwiSaver Scheme ANZ Default KiwiSaver Scheme

Bring your Australian super home. ANZ KiwiSaver Scheme ANZ Default KiwiSaver Scheme Bring your Australian super home ANZ KiwiSaver Scheme ANZ Default KiwiSaver Scheme If you ve worked in Australia at any time since 1992, you may have some Australian super tucked away. You can transfer

More information

Application for a departing Australia superannuation payment

Application for a departing Australia superannuation payment Instructions and form for temporary residents Application for a departing Australia superannuation payment How to complete your Application for a departing Australia superannuation (super) payment. WHO

More information

Benefit transfer or payment request

Benefit transfer or payment request AON ELIGIBLE ROLLOVER FUND Benefit transfer or payment request Use this form to request a transfer/rollover of your benefit to another superannuation fund or a benefit payment to you. Transferring or paying

More information

Early Learning Payment Application

Early Learning Payment Application If you need help with this form call us on % 0800 559 009. About the Early Learning Payment What you need to do The Early Learning Payment contributes to the cost of early childhood education for families

More information

Virgin Super How to transfer your super to New Zealand (Trans Tasman Portability)

Virgin Super How to transfer your super to New Zealand (Trans Tasman Portability) Logo to be inserted Virgin Super How to transfer your super to New Zealand (Trans Tasman Portability) NEED HELP? Please refer to the information and relevant websites detailed below. You can call the Customer

More information

UNCLAIMED MONEY HOW TO CLAIM YOUR MONEY

UNCLAIMED MONEY HOW TO CLAIM YOUR MONEY UNCLAIMED MONEY HOW TO CLAIM YOUR MONEY Do not complete this form to claim funds where your search shows the Type of money as 'Banking', 'Life' or 'Company Gazette'; or if you are claiming funds listed

More information

SIGNIFICANT FINANCIAL HARDSHIP - KIWISAVER

SIGNIFICANT FINANCIAL HARDSHIP - KIWISAVER SIGNIFICANT FINANCIAL HARDSHIP - KIWISAVER A significant financial hardship (hardship) withdrawal can help during times of financial difficulty; however the purpose of your KiwiSaver savings is for your

More information

Marriage and Civil Union Celebrants A GUIDE TO THE ROLE OF CELEBRANTS IN NEW ZEALAND

Marriage and Civil Union Celebrants A GUIDE TO THE ROLE OF CELEBRANTS IN NEW ZEALAND Marriage and Civil Union Celebrants A GUIDE TO THE ROLE OF CELEBRANTS IN NEW ZEALAND 2 What is a marriage? A marriage is the formalisation of a relationship between two people, regardless of gender, in

More information

Workers Compensation claim form

Workers Compensation claim form Form Workers Compensation claim form STOP - this form is available to be filled in electronically on the NT WorkSafe web site www.worksafe.nt.gov.au. Fill the form in electronically then save a copy to

More information

Application for Bond Loan and Rental Grant assistance

Application for Bond Loan and Rental Grant assistance Office use only (application number) Bond Loan Rental Grant Application for Bond Loan and Rental Grant assistance The Department of Housing and Public Works provides Bond Loans and Rental Grants to people

More information

Questionnaire Cornwell-Type Claims

Questionnaire Cornwell-Type Claims Sensitive: Personal once completed Questionnaire Cornwell-Type Claims Please complete all sections of this form and enter N/A in any section that is not applicable to indicate that the question has been

More information

APPLICATION FOR DISABILITY BENEFITS

APPLICATION FOR DISABILITY BENEFITS APPLICATION FOR DISABILITY BENEFITS Which official language do you wish to use HO file No. Decision No. Date of application in oral communications? in correspondence? English English French French Which

More information

Completion Certificate Application Form (New Zealand Degree Holders Only) [Effective 15 March 2016]

Completion Certificate Application Form (New Zealand Degree Holders Only) [Effective 15 March 2016] PERSONAL DETAILS [Please Print] Full Legal Name* Completion Certificate Application Form (New Zealand Degree Holders Only) [Effective 15 March 2016] Surname First Name Middle Name(s) Name Used Surname

More information

Student Allowance Transfer Grant application

Student Allowance Transfer Grant application Student Allowance Transfer Grant application The Student Allowance Transfer Grant is a one-off payment to help if you have a partner 1 and/ or child(ren) who are dependent on you and you are in hardship

More information

THE NATIONAL INSURANCE BOARD APPLICATION FOR DEATH BENEFIT

THE NATIONAL INSURANCE BOARD APPLICATION FOR DEATH BENEFIT THE NATIONAL INSURANCE BOARD APPLICATION FOR DEATH BENEFIT (PLEASE USE BLOCK CAPITALS) NI 117 (FOR OFFICIAL USE) CLAIM : TE: This Application must be submitted within twelve (12) months of the Date of

More information

Early release of super on compassionate grounds How to make a claim

Early release of super on compassionate grounds How to make a claim Early release of super on compassionate grounds How to make a claim Please note if you have ceased work due to sickness or injury, call us on 13 11 84 before proceeding. Am I eligible to make a claim?

More information

First Notice of Claim for Illness or Injury

First Notice of Claim for Illness or Injury How to help us process your claim Checklist Before submitting your claim form, make sure you can tick all the boxes below: Illness or Injury claims - documents required Section A: Statement of claimant

More information

Application for Disability Lump Sum SERB Scheme

Application for Disability Lump Sum SERB Scheme Application for Disability Lump Sum SERB Scheme Who should use this form? You should complete this form if you are a SERB Scheme member who is applying for a Disability Lump Sum benefit. Did you know?

More information

Powers of Attorney in New South Wales. This fact sheet also contains the forms to make a general power of attorney or an enduring power of attorney.

Powers of Attorney in New South Wales. This fact sheet also contains the forms to make a general power of attorney or an enduring power of attorney. FACT SHEET www.lpi.nsw.gov.au March 2014 Powers of Attorney in New South Wales This fact sheet also contains the forms to make a general power of attorney or an enduring power of attorney. What is a power

More information

Application for Home Help Payments

Application for Home Help Payments Application for Home Help Payments If you need help with this form call us on % 0800 559 009. Who can get this payment If you need help filling in this form, please ask at your nearest Work and Income

More information